GW1--06096_Well Construction - GW1_20230921

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WELL CONSTRUCTION RECORD For literal useONl Y: f .
Tbis form can be used for single or multiple wells
1..Well ontraetor Information: i
1 A I4.WA ER ZONES •
n. i`7tr� /j I ��J FROM I TO DESCRIPTION
Well ContractorNama' ft. ft.
` 15.OUTER CASING(for multi-eased wells)°RLINER(if ap licable) . •
NC Well Con c[nr Certification Number FROM TO DIAMETER 'THICKNESS MATERIAL
Gt( l &A/ O/4/ 17L AL. r5ft. (>?r t, in.Company Name '16.INNER CASING OR TUBING(geothermal clescd-Loop)-' '
�t /I t�- FROM TO DIAMETER in. THICKNESS: MATERIAL
2.Well Construction Permit#: ('l fst /lhlvl.�1,3 2 `ii ft.
List all applicable well construction permits(Le.Coast};Stag Variance era) R. In. , : -___"
3.Well Use(check well use): 17.SCREEN • •
Water Supply Well: FROM TO_ • DIAMElE EE(TsIZE THICKNESS MATERIAL
ft In.
DAgricuitural OM cmpal/Public
it,
Clew: thermal(Heating/Cooling Supply) esidential Water Supply(single)
Dltidustrial/Commercial °Residential Water Supply(shared) iFR8,OM GROUT
TO MIAL
[ E�MPJ�CEMENT METHOD&AM ON'.
[litigation 0 ft. D . rib-17
Non-Water Supply Well: ft. ft.
❑Monitoring °Recovery
Injection Well: ft. R. .
°AquiferRecharge °GroundwaterRemediation 19:SAND/GRAVEL PACK(If applicable)• ,
FROM TO MATERIAL • EMP CEMENT METHOD
°Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
°Aquifer Test DStonnwater Drainage R,
°Experimental Technology ❑SubsidenceContro7 20.DRILLING LOG(attach additional sheets it necessary)
°Geothermal(Closed Loop) OTracer FROM TO DESCRI• ON(e,tor,herdnea,santtocktype,grainsize,etc.
❑Geothermal(Heating/CoolingReturn) GOtb-d (explain-under#2l-Remarks)-----8 ft. - , =- , •
fit.. p ej~/--
9 ..�6✓ �3 9�ft 4n
4.Aare Well(s)Completed: (f o. ft 0,,1- :
5.Well Location: i ft ... -
Facility/Owner Name Facility ID#(if applicable) ft. ft. = T: . 77
.0 fvrio Ery ,I.,n1kc'/-> 1 itU ft. ft. V.,-';if""f‘-• k-f v L....1-i
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'Nisi.:.I Ad. ..s,City,and Zip i( 21.REMARKS 1 n
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r 4-eiel ef' i 'I• `�j SEA' 1 L
s
Co:nty Parcel Identification No.(PIN) ^Illis T.cw.^,,.?t•.=44%,<43 iJt'k
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: Q%.Q{:,,-
(ir.won Odd one IaHtong 19 sufficient)
N W
Si re of Certifi onnactor Date
6.4s(are)the well(s): ermanent or °Temporary By signing this form,I hereby certify that the well(s)Was;(were)constructed in accords
with 154 NCelC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and th
.7.Is this a repair to an existing well: °Yes or ICNo copy of this record has'been provided to the well owner.
If this is a repair,fill out known well construction information and et—plots;the nature of the 23.Site diagram or additional well details:
repair under#21 remarks section or on the back of this form.
You may use the back of this page to provide additional well site details or t
S:,Nutnber of wells constructed:
_ _ _ construction details. You may also attach additional pages if necessary,
For multiple Injection or non-water supplY wells ONLY wttb the same construction,you can 24.Submittal Instructions:
submit one form,
/� f1 24a.For Ail.Wells: Submit this form within 30-days of completion of t
.9.,Total well depth below land surface: tI.P V ( ) construction to the following
For multiple wells list all depths Ifdl(Terent(example-3 00'and K f 0 -
1tl.Static water level below top of casing: t% (ft.) Division of Water Quality,Information Processing Unit,
Ifavater level IS above casing,use"+" 1617(Mail Service Center,R le-1g1,NC,27699-1617
i • f'f 1 (In.) 24b.For Iniection.Wells: In addition to sending the form to the address in
11.Borehole diameter: above, also submit a•copy of this form within 30 days of completion of•
v
12.Well construction method: construction to the following:
(i e.auger,rotary,:solo,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
13.FOR WA fat SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Geothermal Wells: In addition to sending the fon
13a.Yield(gpm) Method of test: the address(es) above, also submit one copy of thin form within 30 days
• Amount: completion of well construction to the county health department of the coi
1b.Disinfection type: where constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised:
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